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Private Client In-take Form
In this form you will be asked questions concerning your health history, lifestyle, and objectives.
Name (First, Last) *
Your answer
Date of Birth *
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DD
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YYYY
Address (Street, City, Zip) *
Your answer
Cell-phone *
Your answer
Weight *
Your answer
Height *
Your answer
Please list all medications, including vitamins, herbal or natural supplements and prescription medications,which you are currently taking. *
Your answer
Please indicate if you have/had any of the following: *
Required
If you answered yes to any of the above, please explain in more detail *
Your answer
Have you had any recent injuries, suffer from chronic pain, or limited mobility? Please explain. (i.e. lower back, knees, ankle fracture etc) *
Your answer
Describe your daily activities: *
How often do you exercise 60 minutes or more? *
What does your exercise routine consist of? (i.e. walking, long distance running, hiking, strength training, group fitness classes) *
Your answer
How many hours of sleep do you average a night? *
How much water do you drink a day? *
Your answer
Describe your eating habits. (How often do you eat out? Cook at home? Do you eat processed foods? Vegan? Paleo? Yo-yo dieting.) *
Your answer
Have you practiced yoga? *
If so, in what settings?
What obstacles/distractions are hindering you from reaching your physical goals? *
Your answer
What is your desired outcome from these private sessions? (build a foundation, advance your practice, improve imbalances, increase flexibility, etc.) *
Your answer
What is your ultimate objective for your yoga practice? (to join a studio, practice on your own, destress, meditate, etc.) *
Your answer
What are your expectations for your session? *
Required
What in your life brings you joy? *
Your answer
Please list your availability: *
Your answer
Please list the best way to contact you *
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